Journal of Hand Therapy xxx (2014) 1e6
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Scientific/Clinical Article
Effects of taping the hand in children with cerebral palsy Hilal Keklicek PT, MSc *, Fatma Uygur PT, PhD, Yavuz Yakut PT, PhD Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Altindag, 06100 Ankara, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 June 2014 Received in revised form 3 September 2014 Accepted 10 September 2014 Available online xxx
Background: Thumb in palm deformity restricts hand function by preventing somatosensory input in children with cerebral palsy who have spasticity in their hands. Objectives: To investigate the effects of thenar palmar tape application with and without pressure on upper extremity function in children with cerebral palsy. Method: 45 children were randomly assigned to one of the thenar taping groups either with or without pressure or to the control group. Nine hole peg test and nine parts puzzle test were used to measure upper extremity function. The two study groups were evaluated initially, with taping 20 min later and 20 min after taping was removed. The control group was evaluated initially, 20 min later and again after 20 min. Results: Intragroup analyses showed that initially there was a difference in favor of the control group: number of pegs placed in the hole in 25 s (p ¼ 0.032); number of puzzle parts placed in the hole in 25 s (p ¼ 0.028). Following 20 min of application, there was no longer any difference between the groups (p ¼ 0.458, p ¼ 0.286 respectively). This was accepted as a manifestation of the effectiveness of taping. Intergroup analyses also showed a carry over effect 20 min after removing the tape only in the palmar pressure group (p ¼ 0.004 and p ¼ 0.014). Conclusion: It was concluded that taping can be an effective option for repositioning the thumb and improves upper extremity function by controlling the thumb in palm mechanically and enabling sensorial input by maintaining the correct hand position. Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Spasticity Thumb in palm Hand function Cerebral palsy Tape
Introduction Background The most common postures of the upper extremity in children with cerebral palsy are shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion, finger flexion, and thumb-inpalm.1 Thumb in palm is a very common problem seen in children with cerebral palsy (CP) and its solution is difficult. The deformity is complex and can include: contracture of the thumb metacarpophalangeal joint or global instability; contractures of the intrinsic muscles and spasticity; extrinsic motor imbalance with over lengthening and/or weakness of the extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus; and contracture and/or weakness of the flexor pollicis longus. Thumb in palm deformity can cause restrictions in functional ability and prevent somatosensory input in these children.2 It is known that mechanoreceptors are important exposition systems for normal function. There are studies suggesting that * Corresponding author. Tel.: þ90 3051576 139, þ90 5447208798 (mobile). E-mail addresses: [email protected], [email protected] (H. Keklicek).
plantar deep pressure along the foot is valuable for normal ambulation,3,4 however there is insufficient evidence to either support or refute the effect of applying palmar pressure to the hand. The aim of this study is to investigate the effectiveness of taping with and without thenar palmar pressure on upper extremity function in children with cerebral palsy who have spasticity in their hands. Current knowledge about motor behavior of prehension movements conveys that sensory input, in particular proprioceptive is of vital importance for movement. Therefore placing the hand in the functional position and enabling the child to feel a correct body image or awareness is the prerequisite of intentional movement.5e7 In addition to rehabilitation protocols, various methods have been used to support hand function by restricting abnormal posture and decreasing spasticity such as casting, orthotics, taping and manual techniques. However, limited data exists to support the effectiveness of taping as an adjunct to treatment in facilitating functional motor skills. Objectives This study was carried out with the aim of determining whether taping the hand of children with moderate spasticity to inhibit
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.09.007
2
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
thumb in palm with and without thenar pressure was effective in enhancing purposeful hand movements, consequently in augmenting function. Methods This study was planned as a randomized placebo controlled parallel group study. Participants 45 children with cerebral palsy undergoing neurodevelopmental therapy in various centers three times a week were the subjects of this study. The participants were randomly allocated into the control (CG) or two study groups namely the taping group (TG) and the taping plus thenar palmar pressure group (PPTG). Patients were considered eligible if they met the following inclusion and exclusion criteria given in Table 1. Children with substantial spasticity on the MMAS of 3 or 4 were also not eligible for inclusion as study participants. The subjects were all evaluated by the same therapist FU to eliminate the variability found in assessing the degree of spasticity. Interventions In our study kinesiotape was used for its nonirritant properties. The tape is latex free, very thin, stretches is the longitudinal plane and conforms to the body, allowing for movement.9,10 When applying tape we did not use any known or advocated technique; we devised are own technique with the rational of partially inhibiting thumb in palm via a tape on the extensor surface of the thumb and an additional three piece tape starting from the anterior proximal wrist crease crossing the first web space than descending to the posterior wrist. All four pieces of tape were secured with a circumferential wrist piece (Fig. 1). In the study groups either elastic tape was applied which controlled the thumb in palm or in addition to this elastic tape a piece of polyurethane material aiming to give thenar pressure was also applied. When pressure was used with taping a half spheric polyurethane piece was used according to child’s hand size to give pressure which was fastened to the thenar eminence with elastic tape. The amount of pressure was regulated so that the child felt the pressure without being irritated and without restriction in grasping functions.
Table 1 Inclusion and exclusion criteria Inclusion criteria
Exclusion criteria
Diagnosed as cerebral palsy
Undergone surgery for the upper extremity Used an orthosis for the upper extremity Has dense sensory and motor loss (muscle grade zero to trace) in the area to be taped
4e14 years old Stable clinical status
Hand and/or wrist spasticity 2-3 according to Modified Modified Ashworth Scale (MMAS)8 Without upper extremity passive range of motion limitation Receiving neurodevelopmental rehabilitation programme regularly Sufficient cognitive level to understand the aim of the study and to follow the directions of the testing protocols
Fig. 1. Position of taping for the spastic hand.
Trapeziometacarpal joint stabilization was provided by retraction, abduction and opposition of the thumb mechanically with tape. These applications were carried out by a therapist experienced in the treatment of children with neurological involvement and the application of elastic tape (HK). Following the initial evaluation, children received intensive treatment for their lower extremities only. Activities that were in accordance to the child’s neurodevelopmental level such as balance, jumping, sit to stand etc. but that would be hard enough for the child to make an effort and could probably exert associated reactions in the upper extremities were chosen during the treatment of the lower extremities. Outcomes Every child was evaluated with the following assessment tools: The Nine Hole Peg Test (NHPT); is a timed measure of fine dexterity and involves placing and removing nine pegs in a pegboard. Several researchers have tested the NHPT to establish norms, test validity and reliability.11 The results have shown that the NHPT is valid and reliable and can be used to determine the effects of treatment in children. Children were tested at a desk and chair of appropriate height with their feet supported on the floor. The pegboard was centered in front of the child with the container on the same side as the hand being tested. All subjects tried the test till they learned the test one day before the application to eliminate the learning effect. At application day, verbal directions were used and modified slightly from standardized instructions provided in Mathiowetz et al12 as subjects were children. A stopwatch was used for timing and the mean of the three trials was recorded. Assuming that all children would not be able to complete the test even if we waited for 5 min we also devised other means of assessing function. We used a nine parts puzzle test (NPPT), developed at our university to be used for children with developmental impairment (Figs. 2 and 3). Note how the interphalangeal joint of the pollicis goes into hyperextension when the patient tries to hold the puzzle peg and how it is corrected when tape is applied. We also measured the:
Number Number Number Number
of of of of
pegs pegs pegs pegs
removed in the NHPT in 25 s. placed in the hole in 25 s. removed in the NPPT test in 25 s. placed in the hole in 25 s.
We chose to count the number of pegs placed and removed from the pegboard in 25 s because in the only normative validation study
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
3
for children aged 4e7 years (one block) and for those who were 8e 14 years (second block). The block randomization was prepared by an investigator with no clinical involvement in the trial. The allocation ratio was 1:1:1 and participants were assigned to one of the three parallel groups in which one was the control group. Allocation was carried out by FU using sequentially numbered opaque sealed envelopes. The therapist who taped and assessed the patients (HK) was blinded to the restricted randomization and allocating procedures. The envelopes were opened by HK only after all baseline assessments were completed for enrolled subjects. After allocation it was not possible to blind the subjects or therapist because of the nature of the treatment. The two study groups were evaluated initially, with taping 20 min later and 20 min after taping was removed. The control group was evaluated initially, 20 min later and again after 20 min. Flow diagram is seen in Table 2. Fig. 2. Patient trying to remove the puzzle pegs preapplication of tape.
of the nine hole peg test with children, Smith and Hong reported that nine year old children requiring special education showed a statistical significant difference in completion time compared to regular students and that they usually required 24.18 s to complete the test. However no details were given regarding the problems that those children had.11 Not all children were able to complete the test. We waited for 300 s and accepted this as an end point. For calculation, the time required to complete the test was accepted as 5 min even if the child got bored and did not or could not finish the test. Eight children among 45 could not complete the test. Sample size An optimal total sample size of 45 children was calculated from the GPower 3.0.10 analysis program. 45 participants, using a power of 0.9, power alpha level at 0.05 and medium high effect size 0.25. The university ethical committee approved our study. Caregivers and subjects gave informed consent (application number is LUT 09/24-47) and the clinical trial identifier number is NCT02073513. Randomization Stratified randomization was used to avoid imbalances among the groups with regards of age. A separate randomization was used
Data analysis Three groups were compared using KruskaleWallis test.13 After which ManneWhitney U test14 was used to determine which group caused the difference. Wilcoxon Signed Rank test15 was used to test within group changes. The p value was set at. 05. Results The age of the control group was 8.2 2.73 years and there were 13 hemiparetic and 2 quadriparetic patients. The age of the taping group was 7.9 2.84 years and there were 13 hemiparetic and 2 quadriparetic patients. The age of the thenar palmar pressure group was 8.13 2.87 years and there were 12 hemiparetic, 2 quadriparetic and 1 triparetic patient. Intra group analysis showed that there was no change in the CG, while in PPTG and TG there were statistically significant differences in favor of post application values. When the control and study groups were compared initially there were differences between the groups in their spasticity and functional levels in favor of the CG; number of pegs placed in the hole in 25 s, p ¼ 0.032; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.028. In other words, the CG displayed a higher level of function at the beginning of the study. After 20 min of application of tape the difference between the CG and study groups was eliminated showing that tape application both with and without pressure had been effective in enhancing upper limb function; number of pegs placed in the hole in 25 s, p ¼ 0.458; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.286. While there was no carry over effect 20 min after removing the tape in the TG, the positive effects sustained in the PPTG. There was a carry over effect 20 min after the taping was removed; number of pegs placed in the hole in 25 s, p ¼ 0.004; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.014. However intergroup comparison of the study groups showed that there was no additional favorable effect of using pressure with taping (p ¼ 0.22) (Table 3). Discussion
Fig. 3. Patient trying to remove the puzzle pegs post application of tape.
We investigated the immediate effect of tape application. The present study demonstrated that in children with cerebral palsy who have moderate spasticity in their hands, the application of tape both with and without pressure to control thumb in palm sign is effective in enhancing functional activities. Also there was a difference between the study groups in that there was a carry over effect 20 min after the tape and pressure was removed in the PPTG while there was no such effect in the TG.
4
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
Table 2 Flow diagram
We did not aim to measure the effect of applying tape (with and without thenar pressure) on spasticity because its clinical importance is questionable. It has been shown that spasticity is not directly related to functional ability and that improvements in motor indicators of spasticity did not always translate into greater gains in functional use of the upper extremity.16,17
A 2011 study aimed to evaluate whether supporting the hand in the antispastic posture with a reflex inhibitor orthosis was translated to improvements in the performance of functional tasks.18 Carda and Molteni19 showed that the application of adhesive taping could lead to higher and faster hypertonus reduction on wrist and finger flexors compared to other treatment options. However in
Table 3 Nine hole peg test (NHPT) and nine parts puzzle test (NPPT) values for pre-post intervention and 20 min later in the control group (CG), taping group (TG), thenar palmar pressure plus (PPTG) Measurements
CG
TG
TPPG
n
X
SD
n
X
SD
n
X
SD
Cs
p
NHPT-r1 NHPT-p1 NPPT-r1 NPPT-p1 NHPT-r2 NHPT-r3 NHPT-p2 NHPT-p3 NPPT-r2 NPPT-r3 NPPT-p2 NPPT-p3
15 15 15 15 15 15 15 15 15 15 15 15
6.20 3.20 6.40 3.47 6.27 6.13 3.27 3.13 6.40 6.33 3.47 3.47
3.26 2.21 3.11 2.07 3.15 3.20 2.28 2.17 2.97 3.02 2.00 2.03
15 15 15 15 15 15 15 14 14 14 14 14
4.47 1.40 4.50 1.43 5.53 5.21 2.33 2.00 5.64 5.14 1.93 1.93
2.88 1.60 2.28 1.40 2.67 2.64 2.02 1.80 2.27 2.45 1.64 2.17
15 15 15 15 15 15 15 15 13 13 13 13
4.13 1.47 5.08 1.85 5.67 5.53 2.53 2.13 6.08 5.85 2.54 2.31
2.42 1.73 2.36 2.15 2.41 2.42 2.39 2.23 2.33 2.41 2.57 2.36
4.210 6.86 4.399 7.176 0.67 0.768 1.56 2.504 1.475 1.710 4.230 4.074
0.122 0.032 0.111 0.028 0.715 0.681 0.458 0.286 0.478 0.425 0.121 0.130
n ¼ number of cases, r ¼ removed, p ¼ placed, KW ¼ KruskaleWallis, MWU ¼ ManneWhitney U. 1: First measurement before application. 2. Second measurement 20 min after application. 3: Third measurement after taping removed.
KW test 3 groups
MWU test TG-PPTG z
p
0.22
0.983
0.222
0.983
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
their study they did not investigate whether the reduction in spasticity caused an improvement in functional activities. We used tape in order to prevent the thumb in palm, positioning the thumb to allow free movement, to open distal sensation areas for sensorial stimulation and improve function of the thumb and other fingers. This application was in accordance with the teachings of Brunnstrom and Bobath, widely practiced by therapists, in upper extremity spasticity for releasing tension in the flexor muscles in which the thumb is pulled out of the palm by a grip around the thenar eminence.20,21 In one of the study groups we also used a piece of polyurethane to make the grip even more firmer. It has been shown that direct manipulation of proprioceptors by pushing or pulling on a muscle belly or attachments is also very effective.22 Our hypothesis was that prolonged stretching of a muscle, in this particular situation continuous tension applied to the thenar muscles, could contribute to autogenic inhibition causing a relaxation in hypertonus and the application design would allow sensorial input during movement. The positive effect of taping on proprioception has also been reported by Simoneau et al23 and Callagan et al.24 We assumed that the effects of taping could be due to the cutaneous stimulation of the sensorimotor and proprioceptive systems. The result of these effects would be the enhancement of functional activities. Another explanation is that improved motion results from an increased recruitment in the motor units of the muscle to perform the activity due to increased proprioceptive stimulus.25 To our knowledge, the only study in the literature concerning the use of kinesiotape in children with various ailments, mainly cerebral palsy, is a 2006 year study by Yasukawa et al in which thirteen children who were receiving rehabilitation services participated. They measured upper-limb functional change prior to use of kinesiotape, immediately after application of the tape, and 3 days after wearing tape by the Melbourne Assessment tool for upper limb function. The authors reported that kinesiotape application could be associated with improvements in upper extremity function. These improvements were noted as long as the tape was applied.26 We chose to assess the children, apply tape for 20 min, take measures, remove the tape and after 20 min take another measurement with the nine hole peg test and nine parts puzzle test. Twenty minutes was chosen arbitrarily mainly because the subjects were children who could easily get bored and this could be an issue if we chose longer periods. Therefore the results are immediate effects of taping. Although intergroup comparisons showed no difference with the application of thenar pressure, there was a carry over effect in the PPTG 20 min after the tape was removed while no such effect was seen in the TG. We have no explanation for this difference, it could have been coincidental. There is no research in the literature, investigating the carry over effect of using tape or pressure to control thumb in palm in upper extremity spasticity. However there are two contradicting studies for tone inhibiting dynamic ankle foot orthoses used for lower extremity spasticity. While Erel et al27 did not find a carry over effect, Mueller and Mc Poil28 reported having found a carry over effect. We used the nine hole peg test to measure the outcome of our intervention because the performance of many tasks of daily living, school activities, and play require fine motor dexterity and the nine hole peg test is an effective test which measures fine dexterity. Although it has not been used in the literature and has no norm, validity or reliability studies, we utilized a nine parts puzzle test to test treatment effects because we know from our experience with children that the colorful and purposeful nature of the test enables the child to comply and thrive to finish the test without becoming bored and resembles features of the nine hole peg test such as nine parts and being a timed test measuring velocity and coordination and also requires small pinch grasp.
5
Limitations There were some limitations noted. Following randomized allocation, the outcome assessor knew which group the patients were in. This was mainly because of the nature of the study. Another limitation is the relatively small number of patients. Due to randomized allocation the functional capacity of the patients in the three groups were not homogenous at the initial evaluation. The children in the control group were better functionally at the beginning of the study. The fact that the functional levels of the groups became homogenous after the application of taping was accepted as a manifestation of effectiveness. The groups could have been more homogeneous at the beginning of the study if the study had been carried out with a larger number of patients. Conclusion It is a challenge for clinicians to incorporate new modalities into therapy programs when they have demonstrable efficacy. Although the use of kinesiotape is very widespread, limited data exists to support its use for repositioning the thumb to facilitate functional motor skills of the upper extremity in the pediatric population and can be used as an adjunct to treatment. Whether using pressure along with taping for positioning the thumb has any additional benefits requires further investigation. The nine parts puzzle test seems to be an effective assessment tool for children. References 1. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet. 2004;363:1619e1631. 2. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am. 1981; Feb;63(2):216e 225. 3. Perry Stephen D, McIlroy William E, Maki Brian E. The role of plantar cutaneous mechanoreceptors in the control of compensatory stepping reactions evoked by unpredictable, multi-directional perturbation. Brain Res. 2000;877:401e 406. 4. Meyer PF, Oddsson LIE, De Luca Carlo J. The role of plantar cutaneous sensation in unperturbed stance. Exp Brain Res. 2004;156:505e512. 5. Sarabon N, Dimitrijevicis MM, Zidar J, Dimitrijevic MR. Remarks on neurocontrol of the hand and significance of afferent input. Zdrav Vestn. 2004;73:II11eII-17. 6. Zackowski KM, Dromerick AW, Sahrma SA, Thach WT, Bastian AJ. How do strength, sensation, spasticity and joint individuation relate to the reaching deficits of people with chronic hemiparesis? Brain. 2004;127:1035e1046. 7. Wingert JR, Burton H, Sinclair RJ, Brunstrom JE, Damiano D. Tactile sensory abilities in cerebral palsy: deficits in roughness and object discrimination. Dev Med Child Neurol. 2008; November;50(11):832e838. 8. Naghdi S, Ansari NN, Azarnia S. Interrater reliability of the Modified Modified Ashworth Scale (MMAS) for patients with wrist flexor muscle spasticity. Physiother Theory Pract. 2008;24:372e379. 9. Kase K, Wallıs J, Kase T. Clinical Therapeutic Applications of the Kinesio Taping Method. 2nd ed. Tokyo: Ken Ikai Co. Ltd; 2003. 10. Kase K, Wallis J. Kinesio Taping in Pediatrics: Fundamentals and Whole-body Taping. New York: LLC; 2006. 11. Smith YA, Hong E, Presson C. Normative and validation studies of the Nine-hole Peg Test with children. Percept Mot Skills. 2000;90:823e843. 12. Mathiowetz V, Weber K, Kashman N, Volland G. Adult norms for Nine Hole Peg Test of finger dexterity. Occup Ther J Res. 1985;5(1):24e38. 13. Kruskal WH, Wallis WA. Use of ranks in one-criterion variance analysis. J Am Stat Assoc. 1952;47(260):583e621. 14. Mann Henry B, Whitney Donald R. On a test of whether one of two random variables is stochastically larger than the other. Ann Math Stat. 1947;18(1):50e 60. 15. Wilcoxon Frank. Individual comparisons by ranking methods. Biom Bull. 1945;1(6):80e83. 16. Hill J. The effects of casting on upper extremity motor disorders after brain injury. Am J Occup Ther. 1994; Mar;48(3):219e224. 17. O’Dwyer NJ, Ada L, Neilson PD. Spasticity and muscle contracture following stroke. Brain. 1996; Oct;119(Pt 5):1737e1749. _ Bek N, Yakut Y, Uygur S. Short- and long-term effects of an 18. Erel S, S¸ims¸ek IE, inhibitor hand splint in post stroke patients: a randomized controlled trial. Top Stroke Rehabil. 2011; May-Jun;18(3):231e237. 19. Carda S, Molteni F. Taping versus electrical stimulation after botulinum toxin type A injection for wrist and finger spasticity. A case-control study. Clin Rehabil. 2005; Sep;19(6):621e626.
6
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
20. Brunnstrom S. Movement Therapy in Hemiplegia. A Neurophysiological Approach. New York: Harper & Row Publishers; 1970. 21. Raine S, Meadows L, Lynch Ellerington M. The Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. United Kingdom: John Wiley & Sons; 2009. 22. Travell JG, Simons DG, eds. Myofascial Pain and Dysfunction, the Trigger Point Manual. Baltimore: Williams & Wilkins; 1984. 23. Simoneau G, Degner R, Kramper C, Kittleson K. Changes in ankle joint proprioception resulting from strips of athletic tape applied over the skin. J Athl Train. 1997;32:141e147. 24. Callaghan MJ, Selfe J, Bagley PJ, Oldham JA. The effects of patellar taping on knee joint proprioception. J Athl Train. 2002;37(1):19e24.
25. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006; Nov 4;333(7575):939. 26. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. Am J Occup Ther. 2006; JanFeb;60(1):104e110. 27. Erel S, Uygur F, Bek N. The effects of dynamic ankle- foot orthoses on functional ambulation activities, weight bearing and spatio-temporal characteristics of hemiparetic gait. Disabil Rehabil. 2011;33(25e26):2605e2611. 28. Mueller K, Mc Poil T. Effect of tone-inhibiting ankle-foot orthosis on the footloading pattern of a hemiplegic adult: a preliminary study. J Prosthet Orthot. 1992;4(2):86e92.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Scientific/Clinical Article
Effects of taping the hand in children with cerebral palsy Hilal Keklicek PT, MSc *, Fatma Uygur PT, PhD, Yavuz Yakut PT, PhD Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Altindag, 06100 Ankara, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 June 2014 Received in revised form 3 September 2014 Accepted 10 September 2014 Available online xxx
Background: Thumb in palm deformity restricts hand function by preventing somatosensory input in children with cerebral palsy who have spasticity in their hands. Objectives: To investigate the effects of thenar palmar tape application with and without pressure on upper extremity function in children with cerebral palsy. Method: 45 children were randomly assigned to one of the thenar taping groups either with or without pressure or to the control group. Nine hole peg test and nine parts puzzle test were used to measure upper extremity function. The two study groups were evaluated initially, with taping 20 min later and 20 min after taping was removed. The control group was evaluated initially, 20 min later and again after 20 min. Results: Intragroup analyses showed that initially there was a difference in favor of the control group: number of pegs placed in the hole in 25 s (p ¼ 0.032); number of puzzle parts placed in the hole in 25 s (p ¼ 0.028). Following 20 min of application, there was no longer any difference between the groups (p ¼ 0.458, p ¼ 0.286 respectively). This was accepted as a manifestation of the effectiveness of taping. Intergroup analyses also showed a carry over effect 20 min after removing the tape only in the palmar pressure group (p ¼ 0.004 and p ¼ 0.014). Conclusion: It was concluded that taping can be an effective option for repositioning the thumb and improves upper extremity function by controlling the thumb in palm mechanically and enabling sensorial input by maintaining the correct hand position. Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Spasticity Thumb in palm Hand function Cerebral palsy Tape
Introduction Background The most common postures of the upper extremity in children with cerebral palsy are shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion, finger flexion, and thumb-inpalm.1 Thumb in palm is a very common problem seen in children with cerebral palsy (CP) and its solution is difficult. The deformity is complex and can include: contracture of the thumb metacarpophalangeal joint or global instability; contractures of the intrinsic muscles and spasticity; extrinsic motor imbalance with over lengthening and/or weakness of the extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus; and contracture and/or weakness of the flexor pollicis longus. Thumb in palm deformity can cause restrictions in functional ability and prevent somatosensory input in these children.2 It is known that mechanoreceptors are important exposition systems for normal function. There are studies suggesting that * Corresponding author. Tel.: þ90 3051576 139, þ90 5447208798 (mobile). E-mail addresses: [email protected], [email protected] (H. Keklicek).
plantar deep pressure along the foot is valuable for normal ambulation,3,4 however there is insufficient evidence to either support or refute the effect of applying palmar pressure to the hand. The aim of this study is to investigate the effectiveness of taping with and without thenar palmar pressure on upper extremity function in children with cerebral palsy who have spasticity in their hands. Current knowledge about motor behavior of prehension movements conveys that sensory input, in particular proprioceptive is of vital importance for movement. Therefore placing the hand in the functional position and enabling the child to feel a correct body image or awareness is the prerequisite of intentional movement.5e7 In addition to rehabilitation protocols, various methods have been used to support hand function by restricting abnormal posture and decreasing spasticity such as casting, orthotics, taping and manual techniques. However, limited data exists to support the effectiveness of taping as an adjunct to treatment in facilitating functional motor skills. Objectives This study was carried out with the aim of determining whether taping the hand of children with moderate spasticity to inhibit
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.09.007
2
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
thumb in palm with and without thenar pressure was effective in enhancing purposeful hand movements, consequently in augmenting function. Methods This study was planned as a randomized placebo controlled parallel group study. Participants 45 children with cerebral palsy undergoing neurodevelopmental therapy in various centers three times a week were the subjects of this study. The participants were randomly allocated into the control (CG) or two study groups namely the taping group (TG) and the taping plus thenar palmar pressure group (PPTG). Patients were considered eligible if they met the following inclusion and exclusion criteria given in Table 1. Children with substantial spasticity on the MMAS of 3 or 4 were also not eligible for inclusion as study participants. The subjects were all evaluated by the same therapist FU to eliminate the variability found in assessing the degree of spasticity. Interventions In our study kinesiotape was used for its nonirritant properties. The tape is latex free, very thin, stretches is the longitudinal plane and conforms to the body, allowing for movement.9,10 When applying tape we did not use any known or advocated technique; we devised are own technique with the rational of partially inhibiting thumb in palm via a tape on the extensor surface of the thumb and an additional three piece tape starting from the anterior proximal wrist crease crossing the first web space than descending to the posterior wrist. All four pieces of tape were secured with a circumferential wrist piece (Fig. 1). In the study groups either elastic tape was applied which controlled the thumb in palm or in addition to this elastic tape a piece of polyurethane material aiming to give thenar pressure was also applied. When pressure was used with taping a half spheric polyurethane piece was used according to child’s hand size to give pressure which was fastened to the thenar eminence with elastic tape. The amount of pressure was regulated so that the child felt the pressure without being irritated and without restriction in grasping functions.
Table 1 Inclusion and exclusion criteria Inclusion criteria
Exclusion criteria
Diagnosed as cerebral palsy
Undergone surgery for the upper extremity Used an orthosis for the upper extremity Has dense sensory and motor loss (muscle grade zero to trace) in the area to be taped
4e14 years old Stable clinical status
Hand and/or wrist spasticity 2-3 according to Modified Modified Ashworth Scale (MMAS)8 Without upper extremity passive range of motion limitation Receiving neurodevelopmental rehabilitation programme regularly Sufficient cognitive level to understand the aim of the study and to follow the directions of the testing protocols
Fig. 1. Position of taping for the spastic hand.
Trapeziometacarpal joint stabilization was provided by retraction, abduction and opposition of the thumb mechanically with tape. These applications were carried out by a therapist experienced in the treatment of children with neurological involvement and the application of elastic tape (HK). Following the initial evaluation, children received intensive treatment for their lower extremities only. Activities that were in accordance to the child’s neurodevelopmental level such as balance, jumping, sit to stand etc. but that would be hard enough for the child to make an effort and could probably exert associated reactions in the upper extremities were chosen during the treatment of the lower extremities. Outcomes Every child was evaluated with the following assessment tools: The Nine Hole Peg Test (NHPT); is a timed measure of fine dexterity and involves placing and removing nine pegs in a pegboard. Several researchers have tested the NHPT to establish norms, test validity and reliability.11 The results have shown that the NHPT is valid and reliable and can be used to determine the effects of treatment in children. Children were tested at a desk and chair of appropriate height with their feet supported on the floor. The pegboard was centered in front of the child with the container on the same side as the hand being tested. All subjects tried the test till they learned the test one day before the application to eliminate the learning effect. At application day, verbal directions were used and modified slightly from standardized instructions provided in Mathiowetz et al12 as subjects were children. A stopwatch was used for timing and the mean of the three trials was recorded. Assuming that all children would not be able to complete the test even if we waited for 5 min we also devised other means of assessing function. We used a nine parts puzzle test (NPPT), developed at our university to be used for children with developmental impairment (Figs. 2 and 3). Note how the interphalangeal joint of the pollicis goes into hyperextension when the patient tries to hold the puzzle peg and how it is corrected when tape is applied. We also measured the:
Number Number Number Number
of of of of
pegs pegs pegs pegs
removed in the NHPT in 25 s. placed in the hole in 25 s. removed in the NPPT test in 25 s. placed in the hole in 25 s.
We chose to count the number of pegs placed and removed from the pegboard in 25 s because in the only normative validation study
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
3
for children aged 4e7 years (one block) and for those who were 8e 14 years (second block). The block randomization was prepared by an investigator with no clinical involvement in the trial. The allocation ratio was 1:1:1 and participants were assigned to one of the three parallel groups in which one was the control group. Allocation was carried out by FU using sequentially numbered opaque sealed envelopes. The therapist who taped and assessed the patients (HK) was blinded to the restricted randomization and allocating procedures. The envelopes were opened by HK only after all baseline assessments were completed for enrolled subjects. After allocation it was not possible to blind the subjects or therapist because of the nature of the treatment. The two study groups were evaluated initially, with taping 20 min later and 20 min after taping was removed. The control group was evaluated initially, 20 min later and again after 20 min. Flow diagram is seen in Table 2. Fig. 2. Patient trying to remove the puzzle pegs preapplication of tape.
of the nine hole peg test with children, Smith and Hong reported that nine year old children requiring special education showed a statistical significant difference in completion time compared to regular students and that they usually required 24.18 s to complete the test. However no details were given regarding the problems that those children had.11 Not all children were able to complete the test. We waited for 300 s and accepted this as an end point. For calculation, the time required to complete the test was accepted as 5 min even if the child got bored and did not or could not finish the test. Eight children among 45 could not complete the test. Sample size An optimal total sample size of 45 children was calculated from the GPower 3.0.10 analysis program. 45 participants, using a power of 0.9, power alpha level at 0.05 and medium high effect size 0.25. The university ethical committee approved our study. Caregivers and subjects gave informed consent (application number is LUT 09/24-47) and the clinical trial identifier number is NCT02073513. Randomization Stratified randomization was used to avoid imbalances among the groups with regards of age. A separate randomization was used
Data analysis Three groups were compared using KruskaleWallis test.13 After which ManneWhitney U test14 was used to determine which group caused the difference. Wilcoxon Signed Rank test15 was used to test within group changes. The p value was set at. 05. Results The age of the control group was 8.2 2.73 years and there were 13 hemiparetic and 2 quadriparetic patients. The age of the taping group was 7.9 2.84 years and there were 13 hemiparetic and 2 quadriparetic patients. The age of the thenar palmar pressure group was 8.13 2.87 years and there were 12 hemiparetic, 2 quadriparetic and 1 triparetic patient. Intra group analysis showed that there was no change in the CG, while in PPTG and TG there were statistically significant differences in favor of post application values. When the control and study groups were compared initially there were differences between the groups in their spasticity and functional levels in favor of the CG; number of pegs placed in the hole in 25 s, p ¼ 0.032; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.028. In other words, the CG displayed a higher level of function at the beginning of the study. After 20 min of application of tape the difference between the CG and study groups was eliminated showing that tape application both with and without pressure had been effective in enhancing upper limb function; number of pegs placed in the hole in 25 s, p ¼ 0.458; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.286. While there was no carry over effect 20 min after removing the tape in the TG, the positive effects sustained in the PPTG. There was a carry over effect 20 min after the taping was removed; number of pegs placed in the hole in 25 s, p ¼ 0.004; number of puzzle pegs placed in the hole in 25 s; p ¼ 0.014. However intergroup comparison of the study groups showed that there was no additional favorable effect of using pressure with taping (p ¼ 0.22) (Table 3). Discussion
Fig. 3. Patient trying to remove the puzzle pegs post application of tape.
We investigated the immediate effect of tape application. The present study demonstrated that in children with cerebral palsy who have moderate spasticity in their hands, the application of tape both with and without pressure to control thumb in palm sign is effective in enhancing functional activities. Also there was a difference between the study groups in that there was a carry over effect 20 min after the tape and pressure was removed in the PPTG while there was no such effect in the TG.
4
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
Table 2 Flow diagram
We did not aim to measure the effect of applying tape (with and without thenar pressure) on spasticity because its clinical importance is questionable. It has been shown that spasticity is not directly related to functional ability and that improvements in motor indicators of spasticity did not always translate into greater gains in functional use of the upper extremity.16,17
A 2011 study aimed to evaluate whether supporting the hand in the antispastic posture with a reflex inhibitor orthosis was translated to improvements in the performance of functional tasks.18 Carda and Molteni19 showed that the application of adhesive taping could lead to higher and faster hypertonus reduction on wrist and finger flexors compared to other treatment options. However in
Table 3 Nine hole peg test (NHPT) and nine parts puzzle test (NPPT) values for pre-post intervention and 20 min later in the control group (CG), taping group (TG), thenar palmar pressure plus (PPTG) Measurements
CG
TG
TPPG
n
X
SD
n
X
SD
n
X
SD
Cs
p
NHPT-r1 NHPT-p1 NPPT-r1 NPPT-p1 NHPT-r2 NHPT-r3 NHPT-p2 NHPT-p3 NPPT-r2 NPPT-r3 NPPT-p2 NPPT-p3
15 15 15 15 15 15 15 15 15 15 15 15
6.20 3.20 6.40 3.47 6.27 6.13 3.27 3.13 6.40 6.33 3.47 3.47
3.26 2.21 3.11 2.07 3.15 3.20 2.28 2.17 2.97 3.02 2.00 2.03
15 15 15 15 15 15 15 14 14 14 14 14
4.47 1.40 4.50 1.43 5.53 5.21 2.33 2.00 5.64 5.14 1.93 1.93
2.88 1.60 2.28 1.40 2.67 2.64 2.02 1.80 2.27 2.45 1.64 2.17
15 15 15 15 15 15 15 15 13 13 13 13
4.13 1.47 5.08 1.85 5.67 5.53 2.53 2.13 6.08 5.85 2.54 2.31
2.42 1.73 2.36 2.15 2.41 2.42 2.39 2.23 2.33 2.41 2.57 2.36
4.210 6.86 4.399 7.176 0.67 0.768 1.56 2.504 1.475 1.710 4.230 4.074
0.122 0.032 0.111 0.028 0.715 0.681 0.458 0.286 0.478 0.425 0.121 0.130
n ¼ number of cases, r ¼ removed, p ¼ placed, KW ¼ KruskaleWallis, MWU ¼ ManneWhitney U. 1: First measurement before application. 2. Second measurement 20 min after application. 3: Third measurement after taping removed.
KW test 3 groups
MWU test TG-PPTG z
p
0.22
0.983
0.222
0.983
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
their study they did not investigate whether the reduction in spasticity caused an improvement in functional activities. We used tape in order to prevent the thumb in palm, positioning the thumb to allow free movement, to open distal sensation areas for sensorial stimulation and improve function of the thumb and other fingers. This application was in accordance with the teachings of Brunnstrom and Bobath, widely practiced by therapists, in upper extremity spasticity for releasing tension in the flexor muscles in which the thumb is pulled out of the palm by a grip around the thenar eminence.20,21 In one of the study groups we also used a piece of polyurethane to make the grip even more firmer. It has been shown that direct manipulation of proprioceptors by pushing or pulling on a muscle belly or attachments is also very effective.22 Our hypothesis was that prolonged stretching of a muscle, in this particular situation continuous tension applied to the thenar muscles, could contribute to autogenic inhibition causing a relaxation in hypertonus and the application design would allow sensorial input during movement. The positive effect of taping on proprioception has also been reported by Simoneau et al23 and Callagan et al.24 We assumed that the effects of taping could be due to the cutaneous stimulation of the sensorimotor and proprioceptive systems. The result of these effects would be the enhancement of functional activities. Another explanation is that improved motion results from an increased recruitment in the motor units of the muscle to perform the activity due to increased proprioceptive stimulus.25 To our knowledge, the only study in the literature concerning the use of kinesiotape in children with various ailments, mainly cerebral palsy, is a 2006 year study by Yasukawa et al in which thirteen children who were receiving rehabilitation services participated. They measured upper-limb functional change prior to use of kinesiotape, immediately after application of the tape, and 3 days after wearing tape by the Melbourne Assessment tool for upper limb function. The authors reported that kinesiotape application could be associated with improvements in upper extremity function. These improvements were noted as long as the tape was applied.26 We chose to assess the children, apply tape for 20 min, take measures, remove the tape and after 20 min take another measurement with the nine hole peg test and nine parts puzzle test. Twenty minutes was chosen arbitrarily mainly because the subjects were children who could easily get bored and this could be an issue if we chose longer periods. Therefore the results are immediate effects of taping. Although intergroup comparisons showed no difference with the application of thenar pressure, there was a carry over effect in the PPTG 20 min after the tape was removed while no such effect was seen in the TG. We have no explanation for this difference, it could have been coincidental. There is no research in the literature, investigating the carry over effect of using tape or pressure to control thumb in palm in upper extremity spasticity. However there are two contradicting studies for tone inhibiting dynamic ankle foot orthoses used for lower extremity spasticity. While Erel et al27 did not find a carry over effect, Mueller and Mc Poil28 reported having found a carry over effect. We used the nine hole peg test to measure the outcome of our intervention because the performance of many tasks of daily living, school activities, and play require fine motor dexterity and the nine hole peg test is an effective test which measures fine dexterity. Although it has not been used in the literature and has no norm, validity or reliability studies, we utilized a nine parts puzzle test to test treatment effects because we know from our experience with children that the colorful and purposeful nature of the test enables the child to comply and thrive to finish the test without becoming bored and resembles features of the nine hole peg test such as nine parts and being a timed test measuring velocity and coordination and also requires small pinch grasp.
5
Limitations There were some limitations noted. Following randomized allocation, the outcome assessor knew which group the patients were in. This was mainly because of the nature of the study. Another limitation is the relatively small number of patients. Due to randomized allocation the functional capacity of the patients in the three groups were not homogenous at the initial evaluation. The children in the control group were better functionally at the beginning of the study. The fact that the functional levels of the groups became homogenous after the application of taping was accepted as a manifestation of effectiveness. The groups could have been more homogeneous at the beginning of the study if the study had been carried out with a larger number of patients. Conclusion It is a challenge for clinicians to incorporate new modalities into therapy programs when they have demonstrable efficacy. Although the use of kinesiotape is very widespread, limited data exists to support its use for repositioning the thumb to facilitate functional motor skills of the upper extremity in the pediatric population and can be used as an adjunct to treatment. Whether using pressure along with taping for positioning the thumb has any additional benefits requires further investigation. The nine parts puzzle test seems to be an effective assessment tool for children. References 1. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet. 2004;363:1619e1631. 2. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am. 1981; Feb;63(2):216e 225. 3. Perry Stephen D, McIlroy William E, Maki Brian E. The role of plantar cutaneous mechanoreceptors in the control of compensatory stepping reactions evoked by unpredictable, multi-directional perturbation. Brain Res. 2000;877:401e 406. 4. Meyer PF, Oddsson LIE, De Luca Carlo J. The role of plantar cutaneous sensation in unperturbed stance. Exp Brain Res. 2004;156:505e512. 5. Sarabon N, Dimitrijevicis MM, Zidar J, Dimitrijevic MR. Remarks on neurocontrol of the hand and significance of afferent input. Zdrav Vestn. 2004;73:II11eII-17. 6. Zackowski KM, Dromerick AW, Sahrma SA, Thach WT, Bastian AJ. How do strength, sensation, spasticity and joint individuation relate to the reaching deficits of people with chronic hemiparesis? Brain. 2004;127:1035e1046. 7. Wingert JR, Burton H, Sinclair RJ, Brunstrom JE, Damiano D. Tactile sensory abilities in cerebral palsy: deficits in roughness and object discrimination. Dev Med Child Neurol. 2008; November;50(11):832e838. 8. Naghdi S, Ansari NN, Azarnia S. Interrater reliability of the Modified Modified Ashworth Scale (MMAS) for patients with wrist flexor muscle spasticity. Physiother Theory Pract. 2008;24:372e379. 9. Kase K, Wallıs J, Kase T. Clinical Therapeutic Applications of the Kinesio Taping Method. 2nd ed. Tokyo: Ken Ikai Co. Ltd; 2003. 10. Kase K, Wallis J. Kinesio Taping in Pediatrics: Fundamentals and Whole-body Taping. New York: LLC; 2006. 11. Smith YA, Hong E, Presson C. Normative and validation studies of the Nine-hole Peg Test with children. Percept Mot Skills. 2000;90:823e843. 12. Mathiowetz V, Weber K, Kashman N, Volland G. Adult norms for Nine Hole Peg Test of finger dexterity. Occup Ther J Res. 1985;5(1):24e38. 13. Kruskal WH, Wallis WA. Use of ranks in one-criterion variance analysis. J Am Stat Assoc. 1952;47(260):583e621. 14. Mann Henry B, Whitney Donald R. On a test of whether one of two random variables is stochastically larger than the other. Ann Math Stat. 1947;18(1):50e 60. 15. Wilcoxon Frank. Individual comparisons by ranking methods. Biom Bull. 1945;1(6):80e83. 16. Hill J. The effects of casting on upper extremity motor disorders after brain injury. Am J Occup Ther. 1994; Mar;48(3):219e224. 17. O’Dwyer NJ, Ada L, Neilson PD. Spasticity and muscle contracture following stroke. Brain. 1996; Oct;119(Pt 5):1737e1749. _ Bek N, Yakut Y, Uygur S. Short- and long-term effects of an 18. Erel S, S¸ims¸ek IE, inhibitor hand splint in post stroke patients: a randomized controlled trial. Top Stroke Rehabil. 2011; May-Jun;18(3):231e237. 19. Carda S, Molteni F. Taping versus electrical stimulation after botulinum toxin type A injection for wrist and finger spasticity. A case-control study. Clin Rehabil. 2005; Sep;19(6):621e626.
6
H. Keklicek et al. / Journal of Hand Therapy xxx (2014) 1e6
20. Brunnstrom S. Movement Therapy in Hemiplegia. A Neurophysiological Approach. New York: Harper & Row Publishers; 1970. 21. Raine S, Meadows L, Lynch Ellerington M. The Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. United Kingdom: John Wiley & Sons; 2009. 22. Travell JG, Simons DG, eds. Myofascial Pain and Dysfunction, the Trigger Point Manual. Baltimore: Williams & Wilkins; 1984. 23. Simoneau G, Degner R, Kramper C, Kittleson K. Changes in ankle joint proprioception resulting from strips of athletic tape applied over the skin. J Athl Train. 1997;32:141e147. 24. Callaghan MJ, Selfe J, Bagley PJ, Oldham JA. The effects of patellar taping on knee joint proprioception. J Athl Train. 2002;37(1):19e24.
25. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006; Nov 4;333(7575):939. 26. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. Am J Occup Ther. 2006; JanFeb;60(1):104e110. 27. Erel S, Uygur F, Bek N. The effects of dynamic ankle- foot orthoses on functional ambulation activities, weight bearing and spatio-temporal characteristics of hemiparetic gait. Disabil Rehabil. 2011;33(25e26):2605e2611. 28. Mueller K, Mc Poil T. Effect of tone-inhibiting ankle-foot orthosis on the footloading pattern of a hemiplegic adult: a preliminary study. J Prosthet Orthot. 1992;4(2):86e92.
